Beta-blockers and Ambulatory Inotropic Therapy.

BACKGROUND: Continuous infusion of ambulatory inotropic therapy (AIT) is increasingly used in patients with end-stage heart failure (HF). There is a paucity of data concerning the concomitant use of beta-blockers (BB) in these patients. METHODS: We retrospectively reviewed all patients discharged from our institution on AIT. The cohort was stratified into 2 groups based on BB use. The 2 groups were compared for differences in hospitalizations due to HF, ventricular arrhythmias and ICD therapies (shock or antitachycardia pacing). RESULTS: Between 2010 and 2017, 349 patients were discharged on AIT (95% on milrinone); 74% were males with a mean age of 61 ± 14 years. BB were used in 195 (56%) patients, whereas 154 (44%) did not receive these medications. Patients in the BB group had longer duration of AIT support compared to those in the non-BB group (141 [1-2114] vs 68 [1-690] days). After adjusting for differences in baseline characteristics and indication for AIT, patients in the BB group had significantly lower rates of hospitalizations due to HF (hazard ratio [HR] 0.61 (0.43-0.86); P = 0.005), ventricular arrhythmias (HR 0.34 [0.15-0.74]; P = 0.007) and ICD therapies (HR 0.24 [0.07-0.79]; P = 0.02). CONCLUSION: In patients with end-stage HF on AIT, the use of BB with inotropes was associated with fewer hospitalizations due to HF and fewer ventricular arrhythmias.

Prevalence of short stature, underweight, overweight, and obesity among school children in Jordan.

BACKGROUND: The prevalence of short stature (SS) and underweight in Jordan on a national level is unknown. This study aimed to investigate, on a national level, the prevalence of short stature (SS), underweight, overweight, and obesity among school aged children in Jordan. METHODS: This cross-sectional study was conducted from May 2015 to January 2016 and included 2702 subjects aged 6-17 years. Jordan was classified into 3 regions; North, Center (urban), and South (rural). Public and private schools were randomly selected from a random sample of cities from each region. The socioeconomic status of the sampling locations was assessed using several indicators including education, income, healthcare and housing conditions. For each participating subject, anthropometrics were obtained. SS, underweight, overweight and obesity were defined using Center of Disease Control's (CDC) growth charts. Median Z-scores for each region, age and gender were calculated. RESULTS: The Central and Northern regions enjoyed higher socioeconomic status compared to rural Southern regions. The overall prevalence of SS, underweight, overweight, and obesity were 4.9 %, 5.7 %, 17.3 %, and 15.7 %, respectively. SS and underweight were most prevalent in the rural South, while obesity was highest in the Central region. Females were more likely to be overweight, while males were more likely to be obese. Private schools had higher prevalence of obesity and overweight than public ones. CONCLUSIONS: Variations in height and weight among Jordanian school children might be affected by socioeconomic status.

In-Depth Analysis of a Case of Persistent Severe Chronic Thromboembolic Pulmonary Hypertension.

Pulmonary hypertension (PH) is a disease characterized by an increase in the pulmonary vascular resistance that typically progresses to right heart failure and death. It is classified into five groups. Management depends on the group classification. Group four PH, chronic thromboembolic pulmonary hypertension (CTEPH) is thought to be a result of acute pulmonary emboli that cause fibrosis and scarring of the pulmonary arteries with consequent obstruction. The diagnosis of CTEPH is made by identifying perfusion abnormalities on ventilation/perfusion (V/Q) scan. Other studies required for the diagnostic evaluation include transthoracic echocardiogram, right heart catheterization, NT pro-B-type natriuretic peptide and thrombophilia evaluation. Several other tests needed to exclude other causes of pulmonary hypertension include high-resolution computed tomography (HRCT), connective tissue disease evaluation, thyroid function testing, human immunodeficiency virus testing, and liver ultrasonography to exclude portal hypertension. The treatment for CTEPH is surgical pulmonary endarterectomy (PEA). In patients who are not candidates or decline PEA, pulmonary balloon angioplasty may be useful, however, further studies are required. Several pulmonary artery hypertension medications have been studied in the management of inoperable CTEPH or persistent PH following PEA including bosentan (improves hemodynamics but not exercise capacity), macitentan (improves both hemodynamics and clinical parameters), and riociguat (improves both hemodynamics and exercise capacity). However, only riociguat is approved by the Food and Drug Administration for this indication.

Impact of Human Immunodeficiency Virus Infection on Takotsubo Cardiomyopathy Outcomes in a Large Nationwide Sample.

BACKGROUND/PURPOSE: Takotsubo cardiomyopathy (TCM) or stress-induced cardiomyopathy is characterized by transient wall-motion abnormalities often preceded by physical or emotional stress. Various baseline medical comorbidities were associated with worse outcomes, theoretically due to their effect on chronic stress exposure. The effect of concurrent human immunodeficiency virus (HIV) infection on outcomes of TCM has not been well-established. METHODS/MATERIAL: We conducted a US-wide analysis of TCM hospitalizations from 2006 to 2014 by querying the National Inpatient Sample database for the International Classification of Diseases, Ninth Revision TCM code, baseline characteristics, and inpatient outcomes. TCM patients with HIV were compared to TCM patients without HIV. Multivariate regression models were constructed to account for potential confounders. RESULTS: We identified 123,050 patients hospitalized with TCM; of those patients, 304 had positive HIV status. In an unadjusted analysis, in-hospital outcomes were worse in TCM patients with HIV infection in terms of development of acute kidney injury (16.8% vs 33.3%, P-value 0.002), use of invasive mechanical ventilation (18.3% vs 34.5%, P-value 0.003), and mortality (5.3% vs 17.1%, P-value <0.0001). After adjusting for age, gender, and comorbidities, there was no significant difference in the captured outcomes. CONCLUSION: TCM patients with concurrent HIV had numerically worse outcomes. After adjusting for potential confounders, the statistical significance no longer existed, suggesting that statistical difference was primarily driven by difference in baseline sociodemographic parameters and coexisting comorbidities.

Disrupting the Electrical Circuit: New Onset Atrial Fibrillation in a Patient With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).

In December 2019, an outbreak of pneumonia cases in Wuhan, China was attributed to a novel coronavirus that was eventually recognized as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Currently identified as coronavirus disease 2019 (COVID-19), it has been declared a pandemic by the World Health Organization given its rapid global transmission. Various cardiovascular complications have been reported, including heart failure, myocarditis, acute coronary syndrome and arrhythmias, both atrial and ventricular. Regarding arrhythmias, onset from time of infection is variable but usually ranges from several days to a week. We hereby present a case of a COVID-19 positive patient presenting with new onset atrial fibrillation.

Air Bubbles in the Heart: A Case of Contrast Media Injection-Induced Venous Air Embolism.

Venous air embolism (VAE) is more frequently recognized nowadays with the increased use of computed tomography (CT). It may be detected during or even after intravenous contrast media injection. A wide range of clinical manifestations exist, ranging from an incidental finding in a clinically asymptomatic patient to obstructive shock and circulatory failure. Those found incidentally are usually small and have no significant effect on circulatory physiology. Larger air emboli, however, may be potentially fatal, and therefore it is important to recognize such a phenomenon in the setting of intravenous contrast media injection.

Optimizing Computed Tomography for Detection of Pulmonary Thromboembolism in Patients With Fontan Circulation.

Congenital heart disease (CHD) patients who have undergone the Fontan procedure or one of its variants usually have altered vascular anatomy. Consequently, this poses a challenge when diagnosing pulmonary thromboembolism (PTE) with computed tomography (CT). Detailed review of the type of surgery performed and the person's individual anatomy beforehand can help in choosing the appropriate diagnostic CT modality and technique. It would also help reduce false-positive and false-negative test results that would otherwise result in unnecessary anticoagulation, as well as avoid needless radiation exposure and additional cost, respectively.

Embolic ST-elevation Myocardial Infarction from Candida Endocarditis.

Infective endocarditis in intravenous drug users is uncommon in left-sided native valves. Adding to the rarity, in this case, is endocarditis from Candida species complicated by ST-elevation myocardial infarction. Embolic myocardial infarction has worse outcomes as compared to other etiologies, and the management of septic embolic myocardial infarction is rather challenging. The management of embolic myocardial infarction from Candida endocarditis vegetation includes antifungal therapy. The use of anti-thrombotic therapy and anticoagulation carries a significant risk of fatal neurologic complications and has been controversial, with limited observational data available. Among percutaneous coronary interventions, balloon angioplasty and stenting have been associated with multiple complications while aspiration embolectomy appears to be a safer option. Surgical management is considered if medical and interventional therapies fail or if there is an indication for valve replacement.

Uncommon Anatomic Predisposition to Myocardial Infarction: A Case of Coronary Artery Ectasia.

Coronary artery ectasia (CAE) is a recognized cause of acute coronary syndrome (ACS), and can be associated with life-threatening complications, including thrombus formation with consequent distal coronary artery embolization. Several studies have demonstrated a higher incidence of cardiovascular adverse events and cardiac death in patients with CAE or coronary artery aneurysms compared to those without such abnormalities. Management of symptomatic CAE is similar to coronary artery disease (CAD), where guideline-directed medical therapy is indicated due to coexistence of CAD with acquired CAE. Percutaneous coronary intervention can be attempted; however, it is challenging, as it is associated with lower procedural success, higher rates of stent thrombosis, and repeat revascularization.

Plaque Rupture-Induced Myocardial Infarction and Mechanical Circulatory Support in Alpha-Gal Allergy.

Alpha-gal (AG) allergy is an IgE-mediated allergic reaction to galactose-alpha-1,3-galactose found in mammalian meat. Heparin, being derived from porcine intestinal tissue, may have a degree of cross-reactivity with AG antigen and thus place patients at risk for allergic and even anaphylactic reactions. This is especially important in patients with myocardial infarction (MI) and mechanical circulatory support, such as a left ventricular assist device (LVAD), since anticoagulation is immediately required. Therefore, individualized assessment and preoperative planning is needed regarding the use of heparin vs. nonheparinoid products in such a population.

Seizure: An Adverse Effect of Regadenoson in Myocardial Perfusion Imaging.

Regadenoson is a selective adenosine 2a (A2a) receptor agonist that is used in cardiac stress testing to evaluate for ischemic heart disease and has largely replaced adenosine in the modern era. Since adenosine receptors are involved in synaptic transmission between neurons throughout the central nervous system (CNS) including the cerebral cortex, hippocampus, and other structures as well, regadenoson can lower the seizure threshold in susceptible individuals. Epileptogenic activity is an uncommon yet potentially severe adverse effect of regadenoson use, and therefore, more awareness is required in screening patients at risk and evaluating alternate ways to investigate coronary artery disease (CAD) in susceptible individuals.